Key summary of German national guideline for adult patients with nosocomial pneumonia- Update 2024 Funding number at the Federal Joint Committee (G-BA): 01VSF22007.

PURPOSE: This executive summary of a German national guideline aims to provide the most relevant evidence-based recommendations on the diagnosis and treatment of nosocomial pneumonia. METHODS: The guideline made use of a systematic assessment and decision process using evidence to decision framework (GRADE). Recommendations were consented by an interdisciplinary panel. Evidence analysis and interpretation was supported by the German innovation fund providing extensive literature searches and (meta-) analyses by an independent methodologist. For this executive summary, selected key recommendations are presented including the quality of evidence and rationale for the level of recommendation. RESULTS: The original guideline contains 26 recommendations for the diagnosis and treatment of adults with nosocomial pneumonia, thirteen of which are based on systematic review and/or meta-analysis, while the other 13 represent consensus expert opinion. For this key summary, we present 11 most relevant for everyday clinical practice key recommendations with evidence overview and rationale, of which two are expert consensus and 9 evidence-based (4 strong, 5 weak and 2 open recommendations). For the management of nosocomial pneumonia patients should be divided in those with and without risk factors for multidrug-resistant pathogens and/or Pseudomonas aeruginosa. Bacterial multiplex-polymerase chain reaction (PCR) should not be used routinely. Bronchoscopic diagnosis is not considered superior to´non-bronchoscopic sampling in terms of main outcomes. Only patients with septic shock and the presence of an additional risk factor for multidrug-resistant pathogens (MDRP) should receive empiric combination therapy. In clinically stabilized patients, antibiotic therapy should be de-escalated and focused. In critically ill patients, prolonged application of suitable beta-lactam antibiotics should be preferred. Therapy duration is suggested for 7-8 days. Procalcitonin (PCT) based algorithm might be used to shorten the duration of antibiotic treatment. Patients on the intensive care unit (ICU) are at risk for invasive pulmonary aspergillosis (IPA). Diagnostics for Aspergillus should be performed with an antigen test from bronchial lavage fluid. CONCLUSION: The current guideline focuses on German epidemiology and standards of care. It should be a guide for the current treatment and management of nosocomial pneumonia in Germany.

Pneumonectomy with Carinal Sleeve Resection in Patients with Non-Small-Cell Lung Cancer.

BACKGROUND: Carinal sleeve resection with pneumonectomy is one of the rarest procedures in thoracic surgery, but for locally advanced central lung cancer with infiltration of the carina, it is an option to achieve complete resection. Additionally, it might be the method of choice for patients with stump insufficiency after pneumonectomy or in the cases with anastomosis dehiscence after sleeve lobectomy. The aim of this study was to evaluate the morbidity and long-term survival of patients with non-small-cell lung cancer (NSCLC) who underwent sleeve pneumonectomy, either for curative intent or as an option to treat postoperative complications. METHODS: All consecutive patients with NSCLC who underwent carinal sleeve pneumonectomy for the aforementioned indications in our department between December 2021 and September 2003 were included in this study. An analysis of demographic characteristics, perioperative variables, and long-term survival was carried out. Data were evaluated retrospectively. RESULTS: Fifty patients underwent pneumonectomy with carina sleeve resection. Thirty-one cases for curative treatment of NSCLC (primary sleeve pneumonectomy [pSP]) and 19 patients were treated because of postpneumonectomy bronchial stump insufficiency or bronchial anastomosis dehiscence (secondary sleeve pneumonectomy [sSP]). Complications occurred in 30 patients (60%) and the 90-day mortality was 18% (n = 9). Patients with pSP had an estimated overall survival of 39.6 months, compared to estimated overall survival for patients after sSP of 24.5 months (p = 0.01). The N status did not appear to affect outcomes. CONCLUSION: Carinal sleeve resection with pneumonectomy is a feasible procedure with limited morbidity and mortality. This procedure is a reasonable therapeutic option for patients with locally advanced central NSCLC after mandatory patient selection.

Patients with Pulmonary Artery Reconstruction or Double Sleeve Resection Show Inferior Survival than Patients with Bronchial Sleeve Resection for Non-small Cell Lung Cancer.

Sleeve lobectomy or resection with pulmonary artery reconstruction is a technique that allows for resection of locally advanced central lung carcinoma, preserving lung function, and is associated with lower morbidity and mortality than pneumonectomy. This survey aimed to assess the long-term survival comparing different types of sleeve lobectomy and identify risk factors affecting survival.All consecutive patients who underwent anatomical resection for primary non-small cell lung cancer with bronchial sleeve or pulmonary artery reconstruction in our department between September 2003 and September 2021 were included in this study. Cases with carinal sleeve pneumonectomy were excluded. Data were evaluated retrospectively.Bronchial sleeve resection was performed in 227 patients, double sleeve resection in 67 patients, and 45 cases underwent isolated lobectomy with pulmonary artery reconstruction. The mean follow-up was 33.5 months. The 5-year survival was 58.5% for patients after bronchial sleeve, 43.2% after double sleeve, and 36.8% after resection with vascular reconstruction. The difference in overall survival of these three groups was statistically significant (p = 0.012). However, the UICC stage was higher in cases with double sleeve resection or resection with vascular reconstruction (p = 0.016). Patients with lymph node metastases showed shorter overall survival (p = 0.033). The 5-year survival rate was 60.1% for patients with N0 and 47% for patients with N1 and N2 status. Induction therapy, vascular sleeve resection, and double sleeve resection were independent adverse predictors for overall survival in multivariate analysis.Sleeve lobectomy and resection with vascular reconstruction are safe procedures with good long-term survival. However, double sleeve resection and vascular sleeve resection were adverse predictors of survival, possibly due to a higher UICC stage in these patients.

[Comparison of hospitalized patients with SARS-CoV-2 infection in two time periods of the pandemic]. / Vergleich hospitalisierter Patienten mit SARS-CoV-2-Infektion in zwei Phasen der Pandemie.

OBJECTIVE: The aim of the investigation was to compare patients hospitalized with SARS-CoV-2 infection during 2020/2021 and 2022 with respect to the reason for hospitalization as well as severity of disease at admission, during follow-up and clinical outcomes. METHODS: The data of all patients patients hospitalized with SARS-CoV-2 infection during the periods of interest were collected. Severity of disease at admission and during follow-up was compared in all patients who were hospitalized because of SARS-CoV-2 infection. RESULTS: During the period of 2020 to 2021, overall n=1281 patients with SARS-CoV-2 infection were hospitalized as compared to n=580 in 2022. Of these, 90% and 42%, respectively, were admitted because of SARS-CoV-2 infection. The rates of nosocomial transmission increased from 5 to 18%. Severity of disease at admission and during follow-up was higher across all age groups in the first period. More patients were admitted to the ICU (25 versus 4%). Accordingly, hospital mortality was higher (17 versus 10%). Intubated patients had a high mortality of 74 and 80%, respectively, in both periods. CONCLUSIONS: The severity at admission and during follow-up was much higher in the first period. In the second period, the burden of health care systems was only in part driven by disease severity but more by the need for isolation and nosocomial infections. Mortality of intubated patients was high.

[Chest ultrasound for imaging of pneumonia]. / Sonografie des Thorax zur Diagnostik und Verlaufsbeurteilung der Pneumonie.

Diagnosis of pneumonia can be challenging, particularly the differential diagnosis of lower respiratory tract infection and pneumonia, acute respiratory failure, the diagnosis of nosocomial pneumonia and in case of treatment failure. As compared to conventional chest radiography and CT of the scan, sonography of the chest offers advantages. It could be demonstrated that it was even superior to chest radiography in the identification of pneumonic consolidations. Since most pneumonias affect the lower lobes and include the pleura, pneumonic substrates could be identified in up to 90% of cases despite the limited penetration depth of lung ultrasound. Sonography of the chest has become an established method in the diagnosis of both adult as well as in pediatric community-acquired pneumonia. In addition, it is particularly powerful when used within a point of care (POCUS) approach which also includes the evaluation of the heart. Finally, it appears to have significant potential also in the diagnosis of nosomomial pneumonia and in the evaluation of treatment response, both in the ward as in the ICU.

A case of tracheobronchial amyloidosis with emphasis on differential diagnosis.

Tracheobronchial amyloidosis is a manifestation of amyloidosis of the respiratory tract characterized by focal or diffuse deposition of amyloid in the submucosa of the trachea and proximal bronchi. Tracheobronchial amyloidosis is not associated with systemic amyloidosis or pulmonary parenchymal involvement. It affects predominantly men aged over fifty. Depending on the part of the tracheobronchial tree that is affected, stenosis of the airways causes a variety of unspecific symptoms. Diagnosis is reached by means of typical presentation in CT scan followed by bronchoscopy and histopathological confirmation. Tracheobronchial amyloidosis should be borne in mind in the differential diagnosis of patients with chronic cough and/or dyspnea or recurrent respiratory infections.

Aspergillus niger pneumonia as superinfection in a patient with pulmonary tuberculosis.

We report a patient with severe cavitary pulmonary tuberculosis and Aspergillus niger superinfection, whose only comorbidity was untreated diabetes mellitus. A. niger pneumonia was proven by PCR, sequencing and culture of pleural and respiratory secretions. The patient was successfully treated with a four-drug antituberculous regimen, liposomal amphotericin B (up to 5 mg/kg/d) and pleuro-pneumonectomy. Histology of the resected lung revealed destroyed lung tissue with inflammatory cells and fungal conidia. There were large deposits of polarising material, which was found to be calcium oxalate. There was also nodular caseating necrosis bordered by epitheloid cells and connective tissue. Thus, all diagnostic criteria for invasive A. niger infection were met. Several local risk factors, such as extensive lung damage and tissue acidification, may have favoured superinfection by A. niger. This case highlights the diagnostic value of calcium oxalate crystals in lung tissue and the need for combined antimicrobial and surgical treatment in extensive invasive aspergillosis caused by A. niger.

Image-based lung functional radiotherapy planning for non-small cell lung cancer.

BACKGROUND: This simulation study assessed the feasibility and impact of incorporating additional information from lung perfusion single-photon emission computed tomography (SPECT) into intensity-modulated radiotherapy planning for the treatment of non-small cell lung cancer (NSCLC). METHODS: In this simulation study, data of 13 patients with stage I-III NSCLC previously treated by radio(chemo)therapy were used. The SPECT was fused together with radiotherapy planning CT. Functional lung regions (FL) and non-functional lung regions (nFL) were defined based on SPECT images. Four treatment plans were created for each patient: an IMRT and a VMAT plan with planning CT (anatomical plans), and an IMRT and a VMATplan which integrate the additional information from lung perfusion scintigraphy (function plans). Dosimetric parameters were compared between all plans for PTV parameters and normal tissue preservation, focusing on optimizing the lung volume receiving at least 20 Gy (V20Gy). RESULTS: Compared to anatomical plans, functional IMRT and functional VMAT plans reduced functional lung V20Gy in all cases of local and diffuse hypoperfusion patterns of SPECT defects. Similar results were observed for functional lung V30Gy and median dose to functional lung Dmean, but were not statistically significant in any group. A significant increase in non-functional lung V20Gy resulted in both functional plans. There were no significant differences in conformity or heterogeneity indices or PTV median doses between either pair of anatomical and functional plans. CONCLUSION: The incorporation of functional imaging for radiotherapy planning in non-small cell lung cancer is feasible and appears to be beneficial in preserving a functional lung in non-small cell lung cancer.

Position Paper for the State-of-the-Art Application of Respiratory Support in Patients with COVID-19.

Against the background of the pandemic caused by infection with the SARS-CoV-2 virus, the German Respiratory Society has appointed experts to develop therapy strategies for COVID-19 patients with acute respiratory failure (ARF). Here we present key position statements including observations about the pathophysiology of (ARF). In terms of the pathophysiology of pulmonary infection with SARS-CoV-2, COVID-19 can be divided into 3 phases. Pulmonary damage in advanced COVID-19 often differs from the known changes in acute respiratory distress syndrome (ARDS). Two types (type L and type H) are differentiated, corresponding to early- and late-stage lung damage. This differentiation should be taken into consideration in the respiratory support of ARF. The assessment of the extent of ARF should be based on arterial or capillary blood gas analysis under room air conditions, and it needs to include the calculation of oxygen supply (measured from the variables of oxygen saturation, hemoglobin level, the corrected values of Hüfner's factor, and cardiac output). Aerosols can cause transmission of infectious, virus-laden particles. Open systems or vented systems can increase the release of respirable particles. Procedures in which the invasive ventilation system must be opened and endotracheal intubation carried out are associated with an increased risk of infection. Personal protective equipment (PPE) should have top priority because fear of contagion should not be a primary reason for intubation. Based on the current knowledge, inhalation therapy, nasal high-flow therapy (NHF), continuous positive airway pressure (CPAP), or noninvasive ventilation (NIV) can be performed without an increased risk of infection to staff if PPE is provided. A significant proportion of patients with ARF present with relevant hypoxemia, which often cannot be fully corrected, even with a high inspired oxygen fraction (FiO2) under NHF. In this situation, the oxygen therapy can be escalated to CPAP or NIV when the criteria for endotracheal intubation are not met. In ARF, NIV should be carried out in an intensive care unit or a comparable setting by experienced staff. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring and readiness for intubation are to be ensured at all times. If the ARF progresses under CPAP/NIV, intubation should be implemented without delay in patients who do not have a "do not intubate" order.

Elaboration of Consensus Clinical Endpoints to Evaluate Antimicrobial Treatment Efficacy in Future Hospital-acquired/Ventilator-associated Bacterial Pneumonia Clinical Trials.

BACKGROUND: Randomized clinical trials (RCTs) in hospital-acquired and ventilator-associated bacterial pneumonia (HABP and VABP, respectively) are important for the evaluation of new antimicrobials. However, the heterogeneity in endpoints used in RCTs evaluating treatment of HABP/VABP may puzzle clinicians. The aim of this work was to reach a consensus on clinical endpoints to consider in future clinical trials evaluating antimicrobial treatment efficacy for HABP/VABP. METHODS: Twenty-six international experts from intensive care, infectious diseases, and the pharmaceutical industry were polled using the Delphi method. RESULTS: The panel recommended a hierarchical composite endpoint including, by priority order, (1) survival at day 28, (2) mechanical ventilation-free days through day 28, and (3) clinical cure between study days 7 and 10 for VABP; and (1) survival (day 28) and (2) clinical cure (days 7-10) for HABP. Clinical cure was defined as the combination of resolution of signs and symptoms present at enrollment and improvement or lack of progression of radiological signs. More than 70% of the experts agreed to assess survival and mechanical ventilation-free days though day 28, and clinical cure between day 7 and day 10 after treatment initiation. Finally, the hierarchical order of endpoint components was reached after 3 Delphi rounds (72% agreement). CONCLUSIONS: We provide a multinational expert consensus on separate hierarchical composite endpoints for VABP and HABP, and on a definition of clinical cure that could be considered for use in future HABP/VABP clinical trials.

M. pneumoniae and C. pneumoniae are no relevant pathogens in critically ill patients with hospital-acquired respiratory tract infections.

PURPOSE: To assess the incidence of Mycoplasma pneumoniae and Chlamydia pneumoniae in the pathogenesis of hospital-acquired respiratory tract infections (RTIs) in critically ill patients. METHODS: This is a retrospective cohort study of all ICU-patients ≥ 18 years with RTI who underwent conventional culture techniques and PCR testing for both M. pneumoniae and C. pneumoniae from respiratory tract specimens (bronchoalveolar lavage or tracheobronchial aspirates) between January 2013 to May 2017 at the Jena University Hospital. RESULTS: In total, 314 patients were included in the analysis. Of these, 210 (66.9%) patients were diagnosed with HAP, 65 (20.7%) with VAP and 39 (12.4%) with VAT. Overall, 73 (30.7%) patients were on mechanical ventilation on the day of microbiological examination. PCR-testing for M. pneumoniae was positive in two patients (0.6%) and for C. pneumoniae in zero patients. CONCLUSIONS: Our study shows that the incidence of M. pneumoniae and C. pneumoniae in the pathogenesis of hospital-acquired RTIs in critically ill patients is negligible. The results support the recommendations of the guidelines not to perform empiric therapy covering these pathogens.

Analysis of acute respiratory infections due to influenza virus A, B and RSV during an influenza epidemic 2018.

PURPOSE: We studied the incidence, morbidity and mortality of all patients presenting in our teaching hospital with proven influenza virus and/or respiratory syncytial virus (RSV) infection during the influenza epidemic season 2018 which was characterized by a predominant incidence of influenza virus B type B of the Yamagata line. METHODS: In the fall of 2017, specific precaution measures in addition to standard measures were implemented, including standardized testing for influenza virus A,B and RSV by multiplex PCR of pharyngeal swabsData from all consecutive patients were analyzed retrospectively. RESULTS: Overall 651 patients were examined for the presence of influenza virus and RSV; 214 patients had influenza virus A (n = 36), B (n = 152), and/or RSV (n = 30), including four patients with dual infection. 86% of cases had influenza virus (80% B), and 14% RSV infection. N = 23 cases were treated as outpatients. The rate of acute viral respiratory infections (influenza virus and RSV) was 191 of 2776 (6.9%) admissions to medical wards. Of n = 191 hospitalized cases, n = 44 cases (20.6%) had nosocomial infection. Viral infections were associated with a high morbidity (pneumonia 28.5%, mortality 4.7%). Independent predictors of prolonged hospitalization were the presence of pneumonia, NIV and renal complications, and independent predictors of pneumonia were age ≥ 65 years, bedridden status and CRP ≥ 2.9 mg/dL. CONCLUSIONS: The rate of nosocomial cases was high despite established precaution measures. RSV was associated with morbidity and mortality comparable to influenza. Pneumonia remains the main complication of acute viral respiratory infections, and antimicrobial treatment should include both antiviral as well as antibacterial agents.

Predictors of Outcomes in Patients with Prolonged Weaning with Focus on Respiratory Tract Pathogens and Infection.

BACKGROUND: The impact of respiratory tract pathogens and infection on outcomes in patients with prolonged weaning is largely unknown. OBJECTIVE: We studied predictors of weaning outcomes (death and failure to achieve spontaneous ventilation) in a population treated during a 3.5-year period in a specialized and certified weaning centre. METHODS: Patient data were retrieved retrospectively from the clinical charts. Complete datasets were available in 173 patients. The following parameters were investigated as potential predictors of both endpoints: age; comorbidities; tracheobronchial pathogens; bacteraemia, pneumonia and number of pneumonias; and number of inhouse treatment cycles (none vs. ≥1). RESULTS: Tracheobronchial pathogens, pneumonia, bacteraemia and the number of antibiotic cycles all significantly increased weaning duration and hospitalisation times. Independent predictors of death were atrial fibrillation (OR 2.6, 95% CI 1.2-5.8, p = 0.02) and tracheobronchial multiresistant Pseudomonas aeruginosa (OR 3.9, 95% CI 1.4-11.0, p = 0.01). Independent predictors of failure to achieve spontaneous ventilation included chronic obstructive pulmonary disease (OR 2.8, 95% CI 1.0-7.8, p = 0.045); neuromuscular disease (OR 8.3, 95% CI 1.2-27.2, p = 0.02); tracheobronchial P. aeruginosa (OR 3.3, 95% CI 1.3-9.3, p = 0.01); Stenotrophomonas maltophilia (OR 7.9, 95% CI 1.4-51.6, p = 0.02); and pneumonia (OR 4.4, 95% CI 1.5-10.9, p = 0.003). CONCLUSIONS: The impact of respiratory tract pathogens and infection on weaning outcomes was remarkable. Predictors of death and failure to achieve spontaneous ventilation differed considerably. A priority may be to investigate preventive strategies against colonisation and infection with respiratory pathogens, particularly P. aeruginosa.

International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT).

The most recent European guidelines and task force reports on hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) were published almost 10 years ago. Since then, further randomised clinical trials of HAP and VAP have been conducted and new information has become available. Studies of epidemiology, diagnosis, empiric treatment, response to treatment, new antibiotics or new forms of antibiotic administration and disease prevention have changed old paradigms. In addition, important differences between approaches in Europe and the USA have become apparent.The European Respiratory Society launched a project to develop new international guidelines for HAP and VAP. Other European societies, including the European Society of Intensive Care Medicine and the European Society of Clinical Microbiology and Infectious Diseases, were invited to participate and appointed their representatives. The Latin American Thoracic Association was also invited.A total of 15 experts and two methodologists made up the panel. Three experts from the USA were also invited (Michael S. Niederman, Marin Kollef and Richard Wunderink).Applying the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology, the panel selected seven PICO (population-intervention-comparison-outcome) questions that generated a series of recommendations for HAP/VAP diagnosis, treatment and prevention.

Seasonality of pathogens causing community-acquired pneumonia.

BACKGROUND AND OBJECTIVE: Seasonal distribution of microbial aetiology in patients with community-acquired pneumonia (CAP) may add important information both for epidemiologists and clinicians. We investigate the seasonal distribution of microbial aetiology in CAP. METHODS: This prospective observational study was carried out in the Hospital Clinic of Barcelona, Spain (January 2003-December 2014). RESULTS: We studied 4431 patients with CAP, of whom 2689 (61%) were males. Microbial aetiology was identified in 1756 patients (40%). CAP was most frequent in winter (34%) but two-third of patients with CAP presented in other seasons. Seasonal variations included Streptococcus pneumoniae (winter 21% vs spring 17% vs summer 14% vs autumn 13%, overall P < 0.001). Influenza viruses were most prevalent in autumn (6%) and winter (5%) compared with spring (3%) and summer (1%) (overall P < 0.001). Legionella pneumophila was most frequent in autumn (4%) and summer (4%) compared with spring (2%) and winter (1%) (overall P < 0.001). Incidence of polymicrobial pneumonia also differed between seasons (winter 7% vs spring 5% vs summer 3% vs autumn 6%, overall P = 0.001). We observed a significant correlation between the lowest seasonal average temperature and polymicrobial pneumonia, pneumococcal pneumonia, and influenza viruses; conversely, L. pneumophila was more common when temperatures were higher. CONCLUSION: CAP should not be regarded as a seasonal disease but occurs throughout all seasons. However, S. pneumoniae, influenza viruses, polymicrobial pneumonia and L. pneumophila are clearly subject to seasonal variations.

Executive Summary: Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society.

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society.

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.

Severity Assessment and the Immediate and Long-Term Prognosis in Community-Acquired Pneumonia.

Severity assessment is a crucial step in the initial management of patients with community-acquired pneumonia (CAP). While approximately half of patients are at low risk of death and can be safely treated as outpatients, around 20% are at increased risk. While CURB-65 (confusion, respiratory rate, blood pressure, urea) and pneumonia severity index (PSI) scores are equally useful as an adjunct to clinical judgment to identify patients at low risk, the so-called minor American Thoracic Society/Infectious Diseases Society of America criteria are predictive of patients in need of intensified treatment (i.e., mechanical ventilation and/or vasopressor treatment). Such patients represent medical emergencies. In elderly patients, CRB-65 (confusion, respiratory rate, blood pressure, age) is no longer predictive of low risk; instead, poor functional status is the best predictor of death. In addition to scores, assessment of oxygenation and unstable comorbidity, as well as lactate and biomarkers remain important to consider. The added value of combined clinical and biomarker risk stratification strategies should be evaluated in large prospective interventional trials.Survivors of hospitalized CAP have a considerable excess long-term mortality. Risk factors include age, male gender, and nursing home residency, as well as increased PSI and CURB-65 scores. Cardiovascular, pulmonary, renal, and neoplastic comorbidities are prominent causes of long-term mortality. Comorbidities are vulnerable to both the acute and chronic subclinical inflammatory challenge delivered by pulmonary infection and are thereby drivers of mortality. Biomarkers are promising in identifying patients at increased risk of long-term mortality. Future studies should develop consistent strategies of risk stratification and intervention to improve long-term outcomes of patients with CAP.

MR-proANP, MR-proADM, and PCT in Patients Presenting with Acute Dyspnea in a Medical Emergency Unit.

BACKGROUND: The evaluation of the role of novel biomarkers in the management of cardiac and pulmonary conditions has received particular attention in recent years. A further particular perspective is the use of biomarker panels in the evaluation of patients presenting with acute dyspnea. METHODS: We prospectively evaluated three biomarkers (MR-proANP, PCT, and MR-proADM) in consecutive patients presenting with acute dyspnea in a medical emergency unit during a 4-week period. Patients received a final diagnosis. Biomarkers were tested for their potential to predict diagnoses and survival. No intervention was done. RESULTS: Overall, n = 172 patients were included. Of these, 32.6 % had acute heart failure, 16.9 % pneumonia, and 5.8 % died. MR-proANP was the highest in patients with acute heart failure and lung embolism. Dyspnea scores and levels of MR-pro-ANP correlated positively. MR-proANP achieved an AUC of 0.83 for the diagnosis of acute heart failure. Using a cut-off of 120 pmol/l, sensitivity was 91.1 % and specificity 50 %. PPV was 46.8 % and NPV 92.1 %. In patients with MR-proANP >300 pmol/l, PPV raised to 67.3 %. MR-proADM had an AUC of 0.84 for the prediction of death. PPV was 16 % and NPV 98.4 %. The AUC of PCT was 0.74 for the diagnosis of pneumonia. Using a cut-off of 0.25 ng/ml, PCT had a sensitivity of 44.8 % and a specificity of 85.3 %. PPV was 38.2 and NPV 88.4 %. Using a lower cut-off of <0.1 ng/ml, NPV reached 92.9 %. CONCLUSIONS: A panel of three biomarkers (MR-proANP, PCT, and MR-proADM) in patients presenting to the emergency unit with acute dyspnea provides information about the probability of acute heart failure, nonsurvival, and pneumonia. These biomarkers achieve low to moderate positive predictive values (PPV) and high negative predictive values (NPV).